Cultural Competency: A Comprehensive Framework J. Emilio Carrillo, M.D., M.P.H. VP Community Health, NewYork-Presbyterian Hospital Associate Professor

Cultural Competency:Cultural Competency:A Comprehensive FrameworkA Comprehensive Framework

J. Emilio Carrillo, M.D., M.P.H.J. Emilio Carrillo, M.D., M.P.H.

VP Community Health, NewYork-Presbyterian HospitalVP Community Health, NewYork-Presbyterian HospitalAssociate Professor Clinical Public Health and Medicine, WCMCAssociate Professor Clinical Public Health and Medicine, WCMC

El CentroEl Centro

May 21, 2010May 21, 2010

El Centro 1971El Centro 1971

► Generated by a desire for Social Justice, Knowledge, Generated by a desire for Social Justice, Knowledge, Diversity and Cultural CompetencyDiversity and Cultural Competency

► Frank Bonilla, Josie Nieves, Judge Caro, Nick Frank Bonilla, Josie Nieves, Judge Caro, Nick Sanchez, Maria Canino, Pedro Pedraza de las Sanchez, Maria Canino, Pedro Pedraza de las Piedras and many othersPiedras and many others

► PRSU and Lewisohn Hall Occupation, Columbia PRSU and Lewisohn Hall Occupation, Columbia College. 1971College. 1971

► A Study of the Misuse of Methylphenidate (Ritalin) A Study of the Misuse of Methylphenidate (Ritalin) on Puerto Rican Schoolchildren in East Harlem, on Puerto Rican Schoolchildren in East Harlem, Aguirre-Molina, Carrillo. 1973Aguirre-Molina, Carrillo. 1973

What is Cultural Competency?What is Cultural Competency?

Cultural competency is the ongoing Cultural competency is the ongoing capacity of healthcare systems, capacity of healthcare systems, organizations and professionals to provide organizations and professionals to provide for diverse patient populations high quality for diverse patient populations high quality care that is safe, family- and patient- care that is safe, family- and patient- centered, evidence-based, and equitable.centered, evidence-based, and equitable.

► National Quality Forum, National Voluntary Consensus National Quality Forum, National Voluntary Consensus Standard, 2009Standard, 2009

What is Cultural Competence?What is Cultural Competence?

► Applies to Systems, Organizations and Professionals Applies to Systems, Organizations and Professionals – educators, social workers, urban planners, health – educators, social workers, urban planners, health providers.providers.

► Ongoing capacity to provide to diverse populations Ongoing capacity to provide to diverse populations services and care that are:services and care that are:

Highest QualityHighest Quality Individual and Family CenteredIndividual and Family Centered EquitableEquitable

► Applies to race, ethnicity, gender, sexual Applies to race, ethnicity, gender, sexual orientation, disabilities.orientation, disabilities.

Principles of Cultural CompetencyPrinciples of Cultural Competency

1.1. Equal access to quality services and care and Equal access to quality services and care and non-discriminatory, person-centered practices non-discriminatory, person-centered practices by educators and providers.by educators and providers.

2.2. Necessary, but not sufficient, to achieving an Necessary, but not sufficient, to achieving an equitable healthcare or educational system. equitable healthcare or educational system.

3.3. An ongoing process and a multi-level approach An ongoing process and a multi-level approach targeting the system, organizational, group, targeting the system, organizational, group, community, and individual levels. Not an community, and individual levels. Not an endpoint, rather a continuous improvement. endpoint, rather a continuous improvement.

4.4. Requires an organizational commitment with a Requires an organizational commitment with a systems approach towards cultural competency.systems approach towards cultural competency.

DomainsDomains

1.1. Leadership Leadership

2.2. Integration into Management Systems and Integration into Management Systems and

Operations Operations

3.3. Care Delivery and Supporting Mechanisms Care Delivery and Supporting Mechanisms

4.4. Workforce Diversity and Training Workforce Diversity and Training

5.5. Community Engagement Community Engagement

6.6. Data Collection, Public Accountability, and Data Collection, Public Accountability, and

Quality Improvement (QI) Quality Improvement (QI)

7.7. Patient-Provider CommunicationPatient-Provider Communication

► LeadershipLeadership

► Integrate Integrate ThroughoutThroughout

► Care deliveryCare delivery

► DiversityDiversity

► CommunityCommunity

► DataData

► CommunicationCommunication

► Quality Improvement for cultural Quality Improvement for cultural competency directly stems from the competency directly stems from the leadership.leadership.

► Commitment to diversity, awareness, Commitment to diversity, awareness, organizational culture, dedicated staff organizational culture, dedicated staff and resources, policies, training and and resources, policies, training and developmentdevelopment






► DataData


Integrate culturally competent care Integrate culturally competent care into management systems:into management systems: Strategic PlanningStrategic Planning Service PlanningService Planning MarketingMarketing Staff evaluation & rewardStaff evaluation & reward



► Care delivery



► DataData


Care Delivery and Supporting MechanismsCare Delivery and Supporting Mechanisms

Providing culturally competent care means Providing culturally competent care means properly addressing the manner in which properly addressing the manner in which

care is delivered, the physical environment care is delivered, the physical environment where that care is delivered, and linkages where that care is delivered, and linkages

with supportive services and providers.with supportive services and providers.






► DataData


A diverse workforce can:A diverse workforce can: Improve access, concordanceImprove access, concordance Expand pool of professionalsExpand pool of professionals Advance culturally competent Advance culturally competent

carecare Reflect the community servedReflect the community served






► DataData


Engage the communityEngage the community Understand the communityUnderstand the community Outreach, involve and investOutreach, involve and invest CBPRCBPR






► Data CollectionData Collection


Data Collection, Public Accountability Data Collection, Public Accountability and Quality Improvementsand Quality Improvements Health Research & Educational Trust Health Research & Educational Trust

(HRET)(HRET) Performance measures (QI)Performance measures (QI) TransparencyTransparency






► DataData

► Communication

Clear patient-provider communication is Clear patient-provider communication is essential for effective care and impacts essential for effective care and impacts quality and adherence:quality and adherence: Language accessLanguage access Interpreter servicesInterpreter services TranslationTranslation Health literacy strategiesHealth literacy strategies Cross-Cultural Communication skillsCross-Cultural Communication skills

(IOM., 2003)(IOM., 2003)

CommunicationCommunication

SatisfactionSatisfaction

AdherenceAdherence

Health OutcomesHealth Outcomes

What is Patient (Individual) Based What is Patient (Individual) Based Cross-Cultural Care? Cross-Cultural Care?

Patient Based Cross-Cultural Care is a Patient Based Cross-Cultural Care is a

dynamic process of care which focuses on dynamic process of care which focuses on

the unique social and cultural the unique social and cultural

characteristics of the patient and provides characteristics of the patient and provides

skills to facilitate communication across skills to facilitate communication across

social and cultural boundariessocial and cultural boundaries..

(Carrillo, ‘04)(Carrillo, ‘04)

How do we provide Patient Based How do we provide Patient Based Cross-Cultural Care ?Cross-Cultural Care ?

1.1. Language interpretationLanguage interpretation

2.2. Understand local populationUnderstand local population

3.3. Avoid cultural categorizationAvoid cultural categorization

4.4. Identify and address areas of Identify and address areas of

cross-cultural sensitivitycross-cultural sensitivity

5.5. Serve the individualServe the individual Be aware of you own personal perspective and pre-Be aware of you own personal perspective and pre-

conceptionsconceptions Explore the patient’s perspectiveExplore the patient’s perspective Explore the patient’s expectationsExplore the patient’s expectations Engage the patient, Earn the trustEngage the patient, Earn the trust (Carrillo, ‘04)(Carrillo, ‘04)

Language InterpretationLanguage Interpretation

● ● Opportunities for Cultural BrokeringOpportunities for Cultural Brokering

● ● Concerns:Concerns:

-- Dual role interpreters (Episodic)Dual role interpreters (Episodic)

-- Ad-hoc interpreters (Family)Ad-hoc interpreters (Family)

-- Errors of omissionErrors of omission

-- False fluencyFalse fluency

-- SubstitutionsSubstitutions

-- EditorializationsEditorializations

(www.hablamosjuntos.o(www.hablamosjuntos.org)rg)

How do we provide Patient How do we provide Patient Based Cross-Cultural Care ?Based Cross-Cultural Care ?

1.1. Language interpretation Language interpretation







Local Population is Defined By:Local Population is Defined By:

► Socio-economic profileSocio-economic profile

► Migration patternsMigration patterns

► Regional co-migrationRegional co-migration

► ReligionReligion

► Cultural TraitsCultural Traits

How do we provide Patient How do we provide Patient Based Cross-Cultural Care ?Based Cross-Cultural Care ?

1.1. Language interpretation Language interpretation







What is Culture?What is Culture?

Shared system of values, beliefs, and learned Shared system of values, beliefs, and learned

patterns of behaviorpatterns of behavior

Not equivalent to ethnicity or raceNot equivalent to ethnicity or race

Dynamic, not staticDynamic, not static

The Three Cultures in the RoomThe Three Cultures in the Room

Culture Goes Both Ways in Clinical Culture Goes Both Ways in Clinical

EncountersEncounters


1.1. Language interpretation Language interpretation 2.2. Understand local populationUnderstand local population3.3. Avoid cultural categorizationAvoid cultural categorization4.4. Identify and address areas of Identify and address areas of

cross-cultural sensitivitycross-cultural sensitivity5.5. Serve the individualServe the individual

Be aware of you own personal perspective and pre-Be aware of you own personal perspective and pre-conceptionsconceptions

Explore the patient’s perspectiveExplore the patient’s perspective Explore the patient’s expectationsExplore the patient’s expectations Engage the patient, Earn the trustEngage the patient, Earn the trust


Identify and address areas of Identify and address areas of cross-cultural sensitivitycross-cultural sensitivity

• Every culture has areas of sensitivityEvery culture has areas of sensitivity

• Sometimes sensitivities clash in the cross-Sometimes sensitivities clash in the cross-cultural encountercultural encounter

– PatientsPatients– StaffStaff

• Be alert to these sensitive areasBe alert to these sensitive areas

(Carrillo, Green, Betancourt (Carrillo, Green, Betancourt ‘99)‘99)

What are some of these sensitive areas?What are some of these sensitive areas?

• Styles of communicationStyles of communication– Informality may be seen as disrespectInformality may be seen as disrespect– Eye contactEye contact– TouchTouch

• Who’s in charge?Who’s in charge?• Gender of professionalGender of professional• Mistrust and PrejudiceMistrust and Prejudice• Food preferencesFood preferences

(Carrillo, Green, Betancourt (Carrillo, Green, Betancourt ‘99‘99

How do you know?How do you know?

SIMPLY ASK!SIMPLY ASK!

RespectRespect

CuriosityCuriosity EmpathyEmpathy

(Carrillo, Green, Betancourt (Carrillo, Green, Betancourt ‘99)‘99)


1.1. Language interpretation Language interpretation 2.2. Understand local populationUnderstand local population3.3. Avoid cultural categorizationAvoid cultural categorization4.4. Identify and address areas of Identify and address areas of

cross-cultural sensitivitycross-cultural sensitivity5.5. Serve the individualServe the individual

Be aware of you own personal perspective and pre-Be aware of you own personal perspective and pre-conceptionsconceptions

Explore the patient’s perspectiveExplore the patient’s perspective Explore the patient’s expectationsExplore the patient’s expectations Engage the patient, Earn the trustEngage the patient, Earn the trust


Explore the patient’s Explore the patient’s perspectiveperspective

• What does the illness or the What does the illness or the symptoms mean to the symptoms mean to the patient?patient?

(Kleinman, Eisenberg, Good, (Kleinman, Eisenberg, Good, 1978)1978)

Picture….Picture….

Why is it important to explore Why is it important to explore the meaning of the illness?the meaning of the illness?

To facilitate diagnosisTo facilitate diagnosis

To enhance patient satisfactionTo enhance patient satisfaction

address patients’ expectations, fearsaddress patients’ expectations, fears

earn patient’s trustearn patient’s trust

strengthen doctor-patient relationshipstrengthen doctor-patient relationship

To promote adherence to therapeutic planTo promote adherence to therapeutic plan

Explore the patient’s Explore the patient’s expectationsexpectations

• What does the patient expect?What does the patient expect?

• Patient’s social contextPatient’s social context

Explore the patient’s Explore the patient’s expectationsexpectations

• What is at stake for the What is at stake for the patient?patient?

►45 year old Puerto Rican woman lives 45 year old Puerto Rican woman lives in East Harlem, “El Barrio,” depressed, in East Harlem, “El Barrio,” depressed, adhering poorly to DM and BP adhering poorly to DM and BP medications. Major concern is medications. Major concern is obtaining Public Housing.obtaining Public Housing.

Patient Provider

Satisfaction Adherence

Mutual Accord

M. A. P. S.

Negotiate

Acknowledge

Present Bio-Med Model (Syntonic)

• What’s wrong?What’s wrong?

• What will What will happen?happen?

• What can I do?What can I do?

• What do you think What do you think is going on?is going on?• What do you What do you expect?expect?• What’s at stake?What’s at stake?


Engage the Patient, Earn the Engage the Patient, Earn the TrustTrust

• AcknowledgeAcknowledge

• ExplainExplain

• NegotiateNegotiate

How do we provide Patient Based How do we provide Patient Based Cross-Cultural Care?Cross-Cultural Care?

Language Language InterpretationInterpretation

Patient’s Patient’s SensitivitiesSensitivities

• Identify Sensitive Identify Sensitive AreasAreas

• Simply AskSimply Ask

Recognize Our Recognize Our Personal Personal Perspective and Perspective and PreconceptionsPreconceptions

Patient’s Patient’s PerspectivesPerspectives

• What does it mean? What does it mean?

• What is expected?What is expected?

• What is at stake?What is at stake?

Engage the Engage the patient, patient, Earn the trustEarn the trust

• Acknowledge Acknowledge

• ExplainExplain

• NegotiateNegotiate


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Documents

Cultural Competency: A Comprehensive Framework J. Emilio Carrillo, M.D., M.P.H. VP Community Health, NewYork-Presbyterian Hospital Associate Professor